Healthcare Provider Details

I. General information

NPI: 1982603189
Provider Name (Legal Business Name): MEDICAL SHOPPE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MAIN ST
HONESDALE PA
18431-1907
US

IV. Provider business mailing address

1101 MAIN ST.
HONESDALE PA
18431
US

V. Phone/Fax

Practice location:
  • Phone: 570-253-7770
  • Fax: 570-251-7809
Mailing address:
  • Phone: 570-253-7770
  • Fax: 570-251-7809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPP414702L
License Number StatePA

VIII. Authorized Official

Name: JUDITH A STEPHENS
Title or Position: PRESIDENT
Credential: RN
Phone: 570-253-7700